In Florida, an insurance claim is an official request for compensation by a policyholder or their authorized beneficiary to an insurance company when covered losses occur. Insurance claims can be filed to receive survivor (death) benefits, settle medical bills or accident-related expenses, and cover repairs for property damage, among others. Typically, the insurer reviews a claim to ensure that the information supplied is valid before approving the payment of compensation. The insurance company can also deny a claim if the information evaluated is invalid.
The Florida Office for Insurance Regulation is the state agency charged with insurance administration. Through the Florida Department of Financial Services (DFS), the office also oversees claims administration and settlement per Chapter 627 of the 2021 Florida Statutes. Floridians with questions about insurance claims or those seeking to file complaints of denied claims can use the Online Insurance Assistance webpage. They can also send emails or call the statewide toll-free helpline at (877) 693-5236 to lodge their complaints.
Depending on who initiates an insurance claim, a claim can either be a first-party or a third-party insurance claim. A first-party insurance claim is made by the policyholder. In contrast, a third-party claim is filed by a person or an enterprise other than the insured/policyholder.
Insurance claims triggered by adverse weather conditions are the most common of all claims in Florida. Hail and wind damage account for the highest insurance claims, with an estimated average of $11,000 per claim.
There are five major groups of insurance claims in Florida:
An insured/policyholder can initiate the insurance claim process in the event of a covered loss or damage as stated in their policy document. The insurance company, upon receipt of the insured’s claim for compensation, sends an adjuster to investigate the claim and make recommendations. The insurer then evaluates their adjuster’s recommendations and decides whether to approve the payment of full or partial compensation or to deny the claim.
The Florida insurance market has different insurance types, and each of them has its unique claim process. Regardless of these differences, the steps involved in filing an insurance claim generally include:
Also, all insurance claims in Florida have a set of common steps that standardize the insurance claim process, and the following terms are used to describe them:
Note that for property and casualty insurance, upon approval of a settlement payout, an insurance carrier must pay the claim in line with the insured’s preferred settlement option. This selection, typically made when purchasing their coverage, allows an insured to receive payment either on the basis of actual cash value or replacement cost. If the claimant is reimbursed with the actual cash value, the claim amount is less because depreciation and the applicable deductible have been deducted. While a replacement cost payout is depreciation-free and is usually recommended as a preferred settlement option since it compensates the claimant with an amount almost equal to the cash value of their home and/or personal property.
To file an insurance claim in Florida, an insured must understand their policy coverage, exclusion terms, and policy limits. While certain peculiarities are associated with each type of insurance, a claimant can, nevertheless, follow these general steps to file an insurance claim:
Step 1: Quickly Contact your insurer
Quickly notifying your insurer about the damage suffered after a covered event is essential to obtaining a timely claim settlement. You may also consider reaching your insurance agent for more personalized and responsive service. Alternatively, you can contact your insurer online or by telephone. Most Florida-licensed insurers maintain 24-hour call services through which insureds can contact them or file claims. You must also pay attention to the specific timeframe required for filing your claim as outlined in your policy document to avoid submitting a late claim.
Step 2: Create a detailed record to support your claim
After receiving your claim, it is typical for an insurance company to investigate its authenticity and assess the degree of damage or injury reported. They usually engage their adjuster to conduct the investigation and gather relevant information. It is vital that you compile a detailed record of the damage or loss, including pictures and videos as supporting evidence. For any property insurance claim you need to also correctly specify any lost/damaged personal property by showing the proof of purchase or using a property journal. Similarly, for health and accident insurance, you must provide a complete record of receipts, pharmacy prescriptions, and other relevant medical documents to authenticate your claim. A police report is similarly required for an auto insurance claim along with the driver information, and the insurance information of the at-fault driver. Furthermore, staying close to the adjuster during the investigation can help you reduce the possibility of an error during the investigation.
For property insurance, you must try to maintain the original state of the damaged site/property for proper assessment. You must never rearrange the incident site or make any repair to mitigate further damage without first recording the original condition of the damage. This vital action helps to ensure that the adjuster obtains an accurate record of the original state of damage and that your claim is not undervalued or denied.
Step 3: Obtain an estimate or a bill for compensation
You must provide the insurer with a specific compensation amount, and in Florida, each insurance type has a distinct way of determining this amount. For instance, in property insurance, a reputable property professional can provide you with a personal estimate of the cost of replacing or repairing your damaged property. You can also obtain a auto repair estimate from a professional Florida-registered repair shop in the case of auto insurance and if the other party caused the accident.
This can help you identify any significant variance between the adjuster’s cost estimates and the actual market value. It may also minimize the likelihood of getting your claim undervalued and increase your odds of obtaining a fair settlement. Of course, to do this properly, you must, again, completely understand your insurance policy terms, limits, and coverage exclusions.
If you have any questions about the insurance claims process, speak to your current insurer and/or to a knowledgeable insurance agent licensed to give professional advice in Florida.
The required time frame to file an insurance claim in Florida varies based on the specific insurance type. Your insurance policy will typically contain a particular timeline for filing a claim. However, it is advisable to file your claim within a reasonable time. For instance, it is considered late if you file an auto insurance claim after four years following the car accident. This is because the statute of limitations on filing car insurance claims is 4 years from the date of the accident (Fla. Stat. 95.11(3)(a)), and your claim will be dismissed after then, regardless of its validity. The same time frame also applies for homeowners’ insurance when you file a claim, except for a hurricane-related claim, which you must file within 3 years from the storm date.
Yes, you can cancel or withdraw your insurance claim in Florida. You can do so by calling your insurance company’s representative and informing them directly. An insurance claim can be canceled for a range of reasons, such as if the claimant opts to pay for the cost of the damage or loss because it is insignificant. You can also cancel a claim if you wish to avoid paying deductibles and dealing with the chance of increased future insurance premiums. Note, however, that canceling your insurance claim will reflect poorly on your insurance record and may still increase your premium costs in the future.
Under Florida State law, no specific timeframe is stipulated for filing insurance claims. A notable exception exists for auto insurance claims where you must first satisfy the pre-condition of obtaining medical attention within the first 14 days after an accident before you can submit a claim. Health insurance policies also require you to file a claim notice 20 days after the occurrence of a covered event or within any reasonable duration (Fla. Stat. 627.610).
Insurance companies that provide property and casualty coverage in Florida are required by law to investigate claims within 90 days after acknowledging receipt of request and proof-of-loss documents. Insurers must complete their investigations within the 30-day window stipulated for PIP claims for auto insurance claims. Generally, insurers must conclude claims investigations within a “reasonable period of time.”
The specific time required for an insurance company to provide a claim check depends on the type of insurance claim involved. Per Florida State laws, a claimant should collect an insurance claim check within 20 days after the concerned disputing parties have agreed to a written settlement (Fla. Stat. 627.4265). A notable exception exists in the case when both parties have mutually agreed to another settlement date. For example, for auto accident insurance claims (specifically PIP claims), a 30-day period is the legally stipulated duration within which insurers must issue claim checks. The insurer must investigate the claims and notify the claimant of their denial or acceptance within this period. If they, however, fail to issue payment within this legally prescribed period or any other mutually agreed date, they will be liable to pay a 12% interest per annum on the overdue claim payment, which is calculated starting from the settlement date.
Yes, you can reopen a closed insurance claim in Florida. Claims are often closed when the claimant fails to effectively communicate or respond to an insurer's settlement offer or request for documentation within the legally stipulated time.
However, state law imposes a statute of limitation of between 2-3 years from the date of loss for reopening a closed property claim (Fla. Stat. 627.70132(2)). You may need to hire a professional insurance dispute lawyer or engage the services of a Florida-Licensed insurance agent to assist you with reopening your closed claim.
Yes, you can. An insured can choose to cancel their claim if they believe they can bear the cost of fixing the resulting damages themselves. Canceling your claim will still impact your insurance record, although it may not affect your future premium payments since it is a zero payout record. Insurance carriers do not care if you cancel your claim since they will not have to pay compensation. But you may not be able to do so if any kind of payout has already been made. In auto insurance, you cannot cancel a claim if you are solely responsible for the damages that necessitated the claim in the first place.
You can cancel your insurance claim by contacting your insurer’s representative over the phone while providing your name and claim number. You must also specify your reasons for canceling and verify if you have any paperwork/documentation to fill out to complete the cancelation process.
Yes, you can. But it is practically impossible to retain the entire payout amount for certain reasons. For instance, you can keep the claim money if you have made out-of-pocket payments while pursuing your claim settlement. The chances of this happening depend on the type of insurance and the applicable policy terms, and the specific settlement guidelines.
Generally, most insurance companies will pay you directly if there are no policy terms dictating payments for attorney fees and contractor fees. In auto insurance for example, an injured claimant cannot keep a PDL-claim payout made by the at-fault party’s insurer, when their health insurer has already covered their medical expenses. In the absence of a medical bill, the payout will then be applied to repairing or replacing any damaged/destroyed property, if the claimant has not made any out-of-pocket payment.
Another instance is in property and casualty insurance where you and your mortgage lender become joint beneficiaries of the claim payout, if you purchased your home via mortgage financing. Also, depending on the mortgage terms, your lending entity may house the claim amount in an escrow account from which payment for the repairs or replacement of damaged property will be made.
Yes, an insurance company in Florida can deny a claim for various reasons. Although insurance companies exist to indemnify covered losses in exchange for paid premiums, they are also for-profit entities. Consequently, they are usually more thorough when settling large losses or handling numerous claims, even when premiums have been dutifully paid. Insurers always find a way to justify every payout made and often accomplish this by employing adjusters to investigate filed claims.
There are several reasons that can cause an insurance company to deny a claim and some of them are:
It is vital for you to read through and properly understand what your insurance covers, along with other policy terms and conditions since your insurer will not operate beyond the scope of your policy. To reduce the chances of having your claims denied, you must ensure that all the necessary information, evidence, and records are readily available for evaluation.
The first step you should take if your insurance carrier denies your claim is to appeal their decision. For instance, auto and property and casualty insurance policies have specific provisions that permit you to contest a denied claim. This is particularly true in situations where you have discovered additional information or new evidence regarding the incident.
If, after an appeal, your insurer still denies your claim, file a complaint with the Florida DFS Consumer Services Division tasked with regulating insurance in the state by calling (877) 693-5236 or online. If all these methods yield no favorable result, you may consider employing the services of an insurance attorney to litigate with your insurer.
It is not mandatory to use the services of a lawyer to settle an insurance claim in Florida since it is only one option out of many to resolve a claim. Hiring an attorney to settle an insurance claim may require more time and effort, especially if a property and casualty claim is involved. You can adhere to these steps to increase your chances of getting an adequate claim settlement without any legal representation:
When an insurance company licensed to operate in the state of Florida denies your claim, you are eligible to appeal the decision or file a lawsuit against them if the appeal fails. However, you must carefully go over the denial notice to understand the reasons for denying your claim. Also, note the procedure and timing for re-filing the claim or appealing the denial.
Typically, some insurance types, such as health insurance, involve a two-step appeal process. First, an internal review where you request for the insurer to conduct a fair and complete review of their decision. If the outcome is not in your favor, an external review is done, and an unbiased third party reviews the claim denial and its reasons. You can pursue litigation if you consider the review outcome unfavorable.
Yes, an insurance company in Florida can deny a claim for different reasons. Since they are for-profit organizations, their business goal is to make a profit and check unjustified losses. So, insurers generally investigate extensively to avoid settling frivolous claims or, if they must, ensure compensations paid are not overvalued.
Per Florida law, an insured who has either made a late premium payment or missed payment can have their claim denied. Insurance carriers are also permitted to deny an insured’s claim if a material misrepresentation was found in their insurance application. Material misrepresentations are usually those facts that directly impact the insurer’s coverage risk assessment and, if revealed to the insurer, would have resulted in higher insurance premiums or rejection of an application. An insurance company in Florida can also deny a claim for the following reasons:
NOTE - It is rare for an insurer to deny an insured’s claim whose policy has been in force for more than 90 days and who has always paid their premiums on time.
First, you must understand that denial is not final and that you have the right to appeal the decision. However, you can only file an appeal within a specified time, and as such, you must scrutinize the denial notice to know the specific directions and deadline set out for the appeal. This notice will also state the insurer’s reasons for denying your claim and whether you are best served by re-submitting the claim or pursuing an appeal.
If your insurance claim is denied, you can opt for the state-sponsored informal alternative dispute resolution programs as provided in Florida Law. This provides the parties involved with an amicable opportunity to resolve their dispute and avoid litigation. A non-partisan mediator from the DFS mediates over this engagement and provides guidance to both the claimant and insurer. The DFS mediator does not insist on any particular outcome, and either party is permitted to reject the outcome of the mediation.
Claimants in Florida can also file complaints of claim denials with the Florida DFS Division of Consumer Services online, by email, or by calling toll-free at (877) 693-5236. If the appeal process fails to yield a claim settlement or results in an under-settlement, you may need to file a lawsuit against the insurer. Obtaining a favorable judgment entitles you to recover the full cost incurred (for court and attorney fees) in pursuing compensation via legal means.
Here are the key takeaways for dealing with denied Florida insurance claim: